Friday Board Review

Infectious Disease Board Review with Dr. Edward Guo

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A 74 year old male with a past medical history of advanced dementia and type 2 diabetes presents via EMS from his long term advanced care facility for cough and shortness of breath. Patient is AOx1 and intermittently follows commands at baseline. EMS reports that the facility nurse noticed that he was hypoxic and had a “nasty cough.” Vitals include Temp 100.6F, HR 110, BP 126/80, RR 22, SpO2 89% on room air. Exam shows a chronically ill, pale appearing older male in mild respiratory distress with a productive cough. Lung sounds are notable for crackles in the lower right lung. A chest x-ray demonstrates focal consolidations of the right middle and right lower lobes with a moderate sized pleural effusion above the right hemidiaphragm. Which of the following laboratory values is NOT part of the diagnostic criteria for an empyema?

A: pleural gram stain of culture

B: pleural LDH

C: pleural pH

D: pleural protein

Answer: pleural protein

This patient is presenting with pneumonia demonstrated by imaging results consistent with the clinical findings of fever, cough, and hypoxia. Pneumonia is the most common cause of an empyema which has specific diagnostic criteria distinct from the Light Criteria for pleural effusions. Approximately 40% of cases have negative cultures. Treatment is drainage and broad spectrum antibiotics with anaerobic coverage.

Diagnostic Criteria for EmpyemaLight Criteria for Exudative Pleural Effusion (requires 1 of the following)
Aspiration of grossly purulent fluid plus one of the following:Pleural protein/serum protein > 0.5
     Positive gram stain or culturePleural LDH/serum LDH > 0.6
     Pleural fluid glucose < 40Pleural LDH > 2/3 upper limit of normal serum LDH
     Pleural pH < 7.2 
     Pleural LDH > 1000 

References:
Mace SE, Anderson E. Lung Empyema and Abscess. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Birkenkamp  K, O’Horo  JC, Kashyap  R,  et al: Empyema management: a cohort study evaluating antimicrobial therapy. J Infect 72: 537, 2016.

Wednesday Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

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A 62 year old male with a history of coronary artery disease s/p recent cardiac stents, atrial fibrillation on Plavix and Eliquis presents to the ED with sudden onset headache, aphasia, and right sided facial deficits. A stroke alert is immediately activated, and non-contrast head CT imaging reveals the image below. What’s the diagnosis?

Answer: Subdural Hematoma

The patient’s anticoagulation was reversed with andexanet alfa. He additionally was provided with one unit of platelets and Keppra for seizure prophylaxis. Ultimately, the patient underwent embolization of the middle meningeal artery with significant clinical improvement of symptoms and was able to be discharged several days later.

Subdural Hematoma Pearls:

  • Crescent shaped hematoma on CT
  • Elderly and alcoholic patients at much higher risk due to brain atrophy
  • Most commonly caused due to acceleration-deceleration injuries with tearing of the bridging veins

Eliquis reversal pearls:

  • Traditionally 4-factor prothrombin complex concentrate (4Factor-PCC) has been used
    • Contains Factors II, VII, IX, and X
  • More recently, andexanet alfa has been developed which functions by binding and inhibiting factor Xa inhibitors

References:

Cline, David, et al. “Head Trauma.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, McGraw-Hill Education, New York, 2020.

Tuesday Advanced Cases & Procedure Pearls

From the Archives: Approach to Refractory SVT by Dr. Richard Byrne (featuring Dr. Eric Hasbun)

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Step 1: Modified Valsalva

  • Have the patient lie in a semi-recumbent position and blow into a standard 10 mL syringe as long as they can.
  • Lay the patient supine and elevate the lower extremities for 1 minute.
Enjoy this demo from the 2019 ResusEM conference with Cooper EM graduate Eric Hasbun (who apparently needs to work on his core)

Step 2: Escalating adenosine doses

  • If standard dose of 6 mg of IV adenosine fails to terminate SVT, escalate subsequent doses by 6 mg.
  • Doses up to 36 mg has been successful in case reports.

Step 3: Attempt an infusion of a Calcium Channel Blocker

  • Diltiazem or verapamil can be given as a slow bolus.
    • Has been shown to be at least as successful, if not more successful, than adenosine in terminating SVT
    • May cause hypotension – treat with fluids and/or IV calcium gluconate

Step 4: If cardioverting, use propofol as sedative

  • Propofol has terminated a variety of tachyarrhythmias in multiple case series.
  • Remember to administer pain medication as propofol has no analgesic effects.
  • Synchronized cardioversion of SVT only requires 50 Joules as initial dose.

References:
Lim SH, Anantharaman V, Teo WS, Chan YH. Slow infusion of calcium channel blockers compared with intravenous adenosine in the emergency treatment of supraventricular tachycardia. Resuscitation 2009; 80:523-528.

Bailey AM, Baum RA, Rose J, Humphries RL. High-Dose Adenosine for Treatment of Refractory Supraventricular Tachycardia in an Emergency Department of an Academic Medical Center: A Case Report and Literature Review. J Emerg Med. 2016 Mar;50(3):477-81.

Appelboam A, Mann C, et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015; 386:1747-53

Friday Board Review

From the Archives: Pediatrics Board Review with Dr. Christine Collins

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An 8 month old male born at 36 weeks without any complications with no medical problems who presents with wheezing, increased work of breathing, rhinorrhea and cough for the past 2 days. On exam, he has a low grade temperature, wheezing in all lung fields, subcostal retractions and nasal flaring. HR is 156 bpm, RR 70, Oxygen saturation is 90% on room air. Mother says other siblings in the house have had a cold the past few days. What is the next step in the management of this patient?

a. Administer IV dexamethasone

b. Administer broad spectrum IV antibiotics

c. Admit with supportive measures

d. Administer inhaled corticosteroids

Answer: Admit with supportive measures

This patient is presenting with acute signs and symptoms of bronchiolitis which include rhinorrhea, cough, wheezes, cough, crackles, use of accessory muscles, and nasal flaring. Babies born prematurely are at increased risk for severe bronchiolitis. Clinically, bronchiolitis occurs primarily <2 years of age, with a peak presentation between 6 and 12 months. 

Treatment for bronchiolitis includes supportive care measures: nasal suctioning and saline drops, oxygen, isotonic fluids, and ventilatory support if needed. Consider hospitalization if persistent increased work of breathing, inability to maintain hydration/feeding, or hypoxia. Beta agonists can be trialed if the patient has a family history suggestive of asthma or atopy. Corticosteroids are not recommended for routine use.

References:

Bjoernsen, L. P., & Ebinger, A. (2016). Chapter 124 Wheezing in Infants and Children In Tintialli’s Emergency Medicine: A Comprehensive Study Guide (8th ed). New York, NY: McGraw-Hill Education.

Cade A, Brownlee KG, Conway SP, et al. Randomised placebo controlled trial of nebulised corticosteroids in acute respiratory syncytial viral bronchiolitis. Arch Dis Child 2000; 82:126

Wednesday Image Review

What’s the Diagnosis? By Dr. Sean Coulson

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52 year old female with a history of breast cancer and recent unilateral mastectomy presents to the ED with the complaint of shortness of breath. Symptoms started earlier this evening and is accompanied by pleuritic, diffuse chest pain, dry cough as well as 4 days of left lateral calf pain. Vital signs include HR 112, RR 30, SpO2 89% on room air, BP 85/61, Temp 99.7F. Physical exam is notable for tachypnea, wheezing throughout all lung fields, and a tender, erythematous left calf. EKG demonstrates sinus tachycardia. A point-of-care cardiac ultrasound is shown below. What’s the most likely diagnosis, and what quantitative ultrasonographic measurement can be obtained to increase your post test probability?

Answer: Massive Pulmonary Embolism; Tricuspid Annular Plane Systolic Excursion (TAPSE)

Primary Use: TAPSE should be incorporated with McConnell sign, D Sign, RV Size and wall thickness and as well as with physical exam / HPI and your pretest probability to determine likelihood of PE. It cannot be used alone to diagnose PE due to the issues listed below.

Steps:

  1. Obtain a high quality Apical 4 image with clear distinction of the right heart free border 
  2. Enable M mode and measure the right heart free border at TV annulus
  3. Measure the excursion between nadir and peak of the TV annulus
  4. Normal > 1.7cm
    • Abnormal is < 1.7cm. Individuals with elevated RV afterload will have diminished RV TV movement.

Limitations of TAPSE:

  • Overall has a limited sensitivity (53%) and specificity (61%) for PE
  • A decreased TAPSE is not specific for PE as other causes of RV strain may have similar findings (Pulmonary HTN, pulmonic stenosis, etc)
  • Assesses TV motion in one plane, ignoring the 3D motion of the TV which may be abnormal in individuals with prior cardiac wall motion abnormalities
  • Numerical value is adversely affected by improper position of the M mode line

References:

https://www.emrap.org/corependium/search?q=TAPSE#h.sb6k765tgtm2

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism?sectionName=Echocardiography&search=tapse&topicRef=120068&anchor=H257411441&source=see_link#H257411441

http://www.emdocs.net/tricuspid-annular-plane-systolic-excursion-tapse-for-risk-stratifying-patients-with-pulmonary-embolism/#:~:text=TAPSE%20for%20Evaluation%20of%20Right%20Ventricular%20Dysfunction&text=Approximates%20RV%20ejection%20fraction%20with,75%25%20specificity%20%5B32%5D.

https://www.thepocusatlas.com/right-ventricular-dysfunction/

Tuesday Advanced Cases & Procedure Pearls

Forehead Swelling by Dr. Edward Guo

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Case: A 12 year old male with a history of autism spectrum disorder and chronic sinusitis presents for forehead swelling. Mother reports that she noticed progressive forehead swelling for about 1 month. She has followed up with the patient’s pediatrician and ENT and given oral cephalexin and fluticasone nasal spray which has not made any changes in symptoms. Patient denies any fevers or headache. Vitals include BP 100/58, HR 90, Temp 97.4F, RR 18, SpO2 98%. Exam is notable for a 3x3cm area of fluctuance centrally located over the forehead with no drainage or surrounding erythema that is minimally tender to palpation.

Differential diagnosis includes: abscess, cyst, lipoma

CT of the facial bones with contrast:

CT interpretation: “Bifrontal and ethmoid sinusitis associated with osseous destruction resulting in a 5 cm bifrontal complex loculated anterior epidural abscess as well as a 3 cm midline frontal subgaleal extracranial scalp abscess. Findings are most consistent with osteomyelitis of the frontal bone and sinuses.”

Case continued: ENT and Neurosurgery are emergently consulted and both recommend transfer to a Pediatric Center for advanced surgical and medical management given extensive nature of infection and reconstruction required post-operatively. The patient is started on broad spectrum antibiotics with vancomycin, ceftriaxone, and metronidazole and transferred to a Pediatric Center ICU with neurosurgical consultation. He was taken to the OR for a bifrontal craniotomy for epidural abscess evacuation and did well post-operatively, discharged on hospital day #4.

Pearls:

  • Pott’s puffy tumor is a rare, life-threatening complication of frontal sinusitis characterized by osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and edema over the forehead and scalp.
  • It can be found in all age groups but most common in adolescents.
  • MRI brain with and without contrast is the preferred imaging modality due to increased sensitivity to detect early intracranial and osseous abnormalities.
  • Treatment is typically surgical intervention with at least 6 weeks of intravenous antibiotics.
    • The infection is typically polymicrobial warranting gram-positive, gram-negative, and anaerobic antibiotic coverage.

References:

Sharma, P., Sharma, S., Gupta, N., Kochar, P., & Kumar, Y. (2017). Pott puffy tumor. Proceedings (Baylor University. Medical Center), 30(2), 179–181. https://doi.org/10.1080/08998280.2017.11929575

Masterson L, Leong P. Pott’s puffy tumour: a forgotten complication of frontal sinus disease. Oral Maxillofac Surg. 2009;13(2):115-117. doi:10.1007/s10006-009-0155-7